Long-term care insurance (Germany)

The long-term care is in the Federal Republic of Germany to hedge the risk , in need of care to be. A distinction is made between statutory long-term care insurance as social insurance and supplementary long-term care insurance.

The social long-term care insurance (SPV) was introduced in 1995 as an independent branch of social insurance and is regulated by law in the Eleventh Book of the Social Code (SGB XI). Corresponding provisions also exist for those with private health insurance who are obliged to take out private long-term care insurance (including private long-term care insurance ; PPV) by virtue of Section 23 SGB XI . Insurance any person who is a member of the statutory health insurance or a private health insurance. Long-term care insurance forms - in addition to statutory health, accident , pension and unemployment insurance - the youngest independent branch of social insurance and thus its “fifth pillar”. Every health insurance company is obliged to offer its policyholders long-term care insurance. Because the principle is that the long-term care health insurance follows, is in the care fund usually a device of the respective health insurance carrier.

Long-term care insurance benefits were granted up to the end of 2016 according to the “levels of need for care”, and since the beginning of 2017 according to the “ care level ”. In the case of professional outpatient or (partially) inpatient care, the costs are covered up to certain maximum amounts (including care aids , measures to improve the living environment and services of volunteer carers ( care allowance )). The long-term care insurance fund fully or partially reimburses the proven costs. In the case of need, there is a right to help with care as a need-oriented supplementary social benefit.

The contribution rate for long-term care insurance is set out in Section 55 (1) SGB XI and rose by 0.2 percentage points to 2.55 or 2.8 percent for childless persons on January 1, 2017 ( Second Care Strengthening Act ) and on January 1, 2019 to 3, 05 or 3.3 percent.

Historical development and classification

With the increase in life expectancy , especially since the middle of the 20th century, the number of people in need of care and the length of time insured people need care have increased. In order to be able to bear the costs of long-term care, those affected had to apply for social assistance more often in the early 1980s than before . In 1978, Bayerische Beamtenkrankenkasse was the first insurance company to offer daily care allowance insurance. In 1981 the 48th conference of health ministers of the federal states discussed the "establishment and financing of outpatient and inpatient care services". In 1984 the Federal Insurance Supervisory Office (predecessor of today's BaFin ) approved the model conditions for long-term care insurance drawn up by private health insurers, and in 1986 16 companies were already offering private long-term care insurance. The federal government at the time ( Kohl II cabinet ) spoke out against statutory long-term care insurance.

The then government in 1990 the State of Baden-Wuerttemberg introduced a bill as a precaution against the financial risk of care in the Federal one. Also because the costs for social welfare agencies continued to rise, four years later on April 22, 1994 the Bundestag and on April 27, 1994 the Bundesrat decided to introduce social long-term care insurance (SPV) with effect from January 1, 1995 by passing SGB XI. as compulsory insurance. Many German economists advocated private, funded coverage of the long-term care risk. The black and yellow federal government ( Kohl IV cabinet ), however, preferred the pay-as-you-go system . The introduction of insurance and its design as a conventionally pay-as-you-go compulsory insurance is associated with the names of Norbert Blüm as the Federal Minister responsible at the time and Karl Jung as State Secretary, known as the "father of long-term care insurance".

In addition, the Care Services Supplementary Act came into force in 2002 and the Care Reorientation Act on October 30, 2012 . On January 1, 2015, the Long-Term Care Strengthening Act I heralded the realignment of long-term care support; Since January 1, 2017, a new definition of the need for long-term care has been in effect in accordance with the Long-Term Care Strengthening Act II (replacement of the previous three care levels with more precise five care levels ) and a new assessment procedure.

Differentiation from other legal provisions

Compensation payments in accordance with Section 35 of the Federal Pension Act (BVG) and the statutory accident insurance benefits have priority over the long-term care insurance benefits ( Sections 13 and 34 SGB XI). The differentiation of the obligation to provide benefits of the various social service providers from one another can be difficult in individual cases because the compensation benefits of the BVG and SGB VII define a different concept of need for care than that according to SGB XI. The assistance for nursing care according to SGB XII (social assistance) occurs only if the service providers mentioned above makes no liability.

application

Long-term care insurance benefits are only granted upon application ( Section 33 (1) SGB XI). The insured person is entitled to apply. Applications under social law can be submitted by anyone who has reached the age of 15 ( Section 36 SGB I). For younger minors, the parents or a guardian act as legal representatives . The applicant can authorize another person ( Section 13 SGB X authorized representatives and advisers). Supervisors represent the adult in need of care when submitting the application, if this is part of their care area.

The long-term care insurance fund must decide on the application within five weeks of receipt of the application and issue a written notification. If this deadline is exceeded and the long-term care insurance fund is responsible for the delay, it must immediately pay the applicant 70 euros for each week that the deadline is exceeded ( Section 18 (3b) SGB XI).

Benefits for the initial application are not provided retrospectively. In contrast, if the need for care increases while the benefits are being paid, the higher benefits may be granted retrospectively from the point in time at which the higher level of care was available ( Section 48 (1) sentence 2 no. 1 SGB X ). If the need for care is reduced, the lower benefits or the discontinuation of the benefits only come into effect retrospectively if the person in need of care knew or did not know due to gross negligence that their entitlement had lapsed in whole or in part ( Section 48, Paragraph 1, Clause 2, No. 4 SGB X).

If benefits have only been approved for a limited period, a new application must be made before the deadline has expired. The long-term care insurance must point this out. A late application will then have the same effect as a new application.

Only those who have been insured for at least two years in the past ten years receive benefits from social long-term care insurance. ( Section 33 (2) SGB XI) If a previously privately insured person changes to social long-term care insurance due to compulsory insurance, the previous uninterrupted period of insurance in private long-term care insurance is fully taken into account. Since January 1, 2019, this also applies if the spouse changes to family insurance; previously there was an unwanted loophole in the law that could lead to an insurance loophole.

Maintenance certificate

The long-term care insurance has the medical service of the health insurance (MDK), Medicproof experts or other independent experts prepare an expert opinion to determine the need for care and the care expenditure. Insofar as independent experts are commissioned to carry out the examination, applicants are usually given three experts to choose from. The assessment is usually carried out in the applicant's living area. If the files are unambiguous, they can be classified into a level of care ( Section 18 (2) SGB XI). The applicant is entitled to receive the report with the notification.

The expert determines whether the conditions for the need for care have been met and the degree of the need for care. It provides information as to whether home care by voluntary caregivers, by an outpatient nursing service or inpatient care is possible. In the case of voluntary home care (e.g. by the partner), an assessment is made as to whether the care appears secure; in the case of deficient care, measures are recommended to ensure care.

If a seamless transition from inpatient hospital treatment to fully inpatient care is necessary, the assessment must be carried out in the hospital within one week at the latest ( Section 18 (3) sentence 3 SGB XI). If, in the case of home care, the caregiver has announced the use of care leave in accordance with the Care Leave Act to the employer or has agreed a family care leave with the employer in accordance with Section 2 (1) of the Family Care Leave Act, an assessment must be carried out within two weeks at the latest (Section 18 (3) sentence 5 SGB XI). Otherwise, the long-term care insurance fund must initiate the assessment immediately after submitting the application, because it should decide on the application within a maximum of five weeks ( Section 18 (3), sentences 1 and 2, SGB XI).

Definition, degrees of care, distinguishing features

With the Second Care Strengthening Act , the previous three care levels and the additional determination of restricted everyday skills were replaced by five care levels.

People in need of care who already had a care level and / or a determination of their limited everyday skills are transferred to the new care levels according to a fixed scheme. These are protected to the extent that they retain their degree of care, even if the application of the new criteria would lead to a lower degree of care. According to Section 141 (1) SGB XI, the benefits granted are also protected: if the application of the new regulations would result in a lower entitlement to ongoing long-term care insurance benefits, the entitlement would remain at the previous level.

The criteria for determining the need for long-term care are set out in Section 14 of Book XI of the Social Code. In need of care is anyone who cannot independently compensate for a physical, mental or psychological disability or a health burden. The need for long-term care must presumably be permanent, at least for six months, and it must be of a certain severity, which is categorized into five degrees of care. The degree of care depends on whether and to what extent the person in need of care can claim benefits from the care insurance.

To determine the need for care, the daily activities are sorted into six categories, which - with different weightings - are included in the care levels. They are:

Mobility (10 percent): the ability to move around your own home, to sit and lie in bed
Cognitive and communicative skills as well as behavior and mental problems (15 percent): these are actually two separate categories; only the category with the higher impairment is taken into account for the need for care.
- The cognitive and communicative skills include spatial and temporal orientation skills, episodic and semantic memory, executive functions, willpower and decision-making power, control skills, intelligence and communication skills.
- Behaviors and psychological problems that are relevant for determining the need for care are, for example, motor disorders, disorders of the day-night rhythm, aggressive behavior towards oneself or others, lack of insight into the disease, delusions, fears, listlessness and lack of social skills.
Self-sufficiency (40 percent): this includes personal hygiene, dressing and undressing, eating and drinking, as well as emptying the bowels and bladder. In the case of infants, there can only be a need if they require an extraordinarily high amount of food intake.
Coping with illness-related requirements (20 percent): What is meant here is the independent use of medication, creams, injections, catheters, measuring devices and other aids, a necessary change of dressing, as well as wound care, visits to the doctor and visits to other therapeutic facilities as well as adherence to an illness-related diet.
Organization of everyday life (15 percent): this is about maintaining a daily structure and regular social contacts.

In the case of children, the need for care is determined by comparing the level of development with healthy children of the same age and taking into account any deficits in the above criteria.

The precise assessment guidelines are now bindingly set out in Appendix 1 to SGB XI. The weighting of the individual impairments within a category is bindingly specified in Appendix 2 to SGB XI. If there is an inability to manage the household independently due to the illness, this must also be taken into account.

Depending on the severity of the need for care, there is a breakdown of the individual care levels according to § 15 SGB XI as follows:

12.5 to below 27 points: care level 1
27 to below 47.5 points: care level 2
47.5 to below 70 points: care level 3
70 to less than 90 points: care level 4
90 points and more: Care level 5

With care level 1, there is actually no need for care; accordingly, according to Section 28a of the Social Code Book XI , such persons are excluded from most long-term care insurance benefits. For the most part, you only receive consulting services.

In special cases of hardship, care level 5 can be granted, even if the total number of points does not reach the limit for care level 5. There is no care level 1 for children; the counting starts with care level 2.

Services

Performance principles

According to Section 5 of Book XI of the Social Code, long-term care insurances must work towards avoiding the need for long-term care through prevention , medical treatment and rehabilitation . If the long-term care insurance determines a need for rehabilitation, it must inform the insured person and, with their consent, the treating doctor and the responsible rehabilitation provider. The notification to the rehabilitation provider counts as a rehabilitation application according to § 14 SGB IX. If an immediate rehabilitation service is required, but the responsible institution cannot provide the service in time, the long-term care insurance must provide provisional rehabilitation services according to Section 32 SGB XI.

Outpatient care takes precedence over semi-inpatient and fully inpatient care services. The services of part-time inpatient care and short-term care have priority over full inpatient care. ( § 3 SGB XI).

All services with the exception of technical aids and care courses are limited in amount. This is an expression of the political will not to design long-term care insurance as full insurance in order to keep contributions stable and to be able to control the development of expenditure.

Home care benefits (home care assistance)

In 2003 around two thirds of benefit recipients opted for outpatient, home care. In the familiar home environment, the majority of those in need of care feel less exposed to psychological stress than when staying in a home. There is, however, an increasing trend in favor of inpatient services.

Care allowance

People in need of care who do not use care assistance from an outpatient care service receive a monthly care allowance . This is intended to support volunteer care and gain recognition. The person in need of care is free to choose how to use the care allowance. For example, it can be used to remunerate a self-chosen volunteer caregiver .

The prerequisite for the care allowance is that home care is ensured in a suitable manner, which is first determined by the expert and checked by care services during regular quality assurance visits.

The monthly care allowance is:

316 euros for care level 2
545 euros for care level 3
728 euros for care level 4
901 euros for care level 5

During full inpatient hospital treatment or rehabilitation, the care allowance will continue to be paid for up to four weeks, after which the entitlement will be suspended.

Insured persons who are temporarily or permanently in an EU country , Iceland , Norway , Liechtenstein or Switzerland are also entitled to care allowance . In the case of stays abroad in other countries, the care allowance can be continued for up to six weeks in the calendar year if the stay is only temporary ( Section 34 SGB XI).

Quality Assurance Visit

A long-term care insurance service belonging to the “cash benefit” is mandatory, regular “quality assurance visits” at home ( Section 37 (3) SGB XI). They serve to advise and ensure sufficient nursing care by the relatives ( lay care ). The caring relatives arrange the visit with an outpatient care service , an advice center recognized by the regional associations of the care insurance funds or a care support point of their choice. The focus is on advice and not on control. Questions that are or can be asked: “How do I make this or that easier? Where can I get aids from? How do I dispense drinks? What are the costs if part of the maintenance is taken over by professionals? How often should the person be stored differently? ... ".

The frequency of such mandatory visits depends on the level of care. A visit takes place every 6 months for care levels 2 and 3, and every 3 months for care levels 4 and 5. People in need of care with care level 1 can make use of the visits voluntarily, although they are not entitled to care allowance. The costs for the use are covered by the long-term care insurance.

If it is determined that home care is not adequately ensured or that care damage has occurred or that there is even a so-called dangerous care situation , the person in need of care loses the right to the care allowance. As a result, care must either be taken over by an outpatient care service or full / part-time inpatient care is required (see the following sections), for which the long-term care insurance fund has to pay. In practice, however, the long-term care funds hardly make use of this option (conflict of interest: the long-term care fund itself decides whether it pays a maximum of EUR 901 care allowance or provides the much higher benefits for inpatient / semi-inpatient care).

Outpatient care service (care in kind)

Long-term care insurance finances an outpatient care service that provides care at home ( care benefit in kind ). The person in need of care has the free choice between the care services that have concluded a supply contract according to §§ 71 ff. SGB XI. The nursing services settle the accounts directly with the nursing care insurance; there is no payment to the person being cared for or their relatives. The monthly maximum amounts depend on the respective level of care:

689 euros for care level 2
1298 euros for care level 3
1612 euros for care level 4
1995 euros at care level 5

Under certain conditions, the care benefit in kind can also be provided by individuals who have concluded a contract with the long-term care insurance in accordance with Section 77 SGB XI. With the change in the law on July 1, 2008, these requirements were expanded to promote such individual contracts. The pooling of benefits in kind from several people in need of care to form a “pool” of benefit entitlements within a social structure, e.g. B. possible within an apartment, a house or a residential area ( § 36 SGB XI).

If more is required for care by a care service than is reimbursed by the care insurance, the additional costs can be claimed for tax purposes as a " household- related service ".

Combined performance

Both care services for home care services can be billed as "material costs" and the unused portion of the maximum amount can be claimed as "cash benefits" for caregivers ( Section 38 SGB XI). For example, if 80% of the maximum amount of the “benefit in kind” is used, 20% of the maximum amount of the care allowance for the respective care level is also available. For example, personal care can be partially carried out by a nursing service (all details on care benefits in kind apply ) and the rest of personal care and domestic care by a family member (all details on care allowance payments apply ... except for the omitted quality assurance visits and social security for the carer ).

According to Section 38 , the person in need of care must decide in which percentage ratio he or she would like to receive care benefits in kind and care allowance and is bound by this decision for a period of six months. In practice, however, early modification is accepted in exceptional cases, for example in the event of a significant change in the care situation. In the event that the care benefit in kind fluctuates from month to month, the procedure has been established that the care fund waits for the care service to be settled, calculates the resulting remaining claim to care allowance and transfers it subsequently.

When the changes in the law came into force on July 1, 2008, the benefits for the combination of care benefit in kind and care allowance with day-care care were improved (see below).

Partial inpatient care (day or night care)

Partial inpatient care is the temporary care during the day in a facility. Partly inpatient care can be designed as day or night care . Long-term care insurance covers the cost of care, social care and medical treatment care costs , depending on the level of care. Due to the subordinate status of § 3 SGB XI of the inpatient services of the long-term care insurance, partial inpatient care is only granted if this is necessary in individual cases because, for example, home care cannot be provided in sufficient quantities.

Example: The carer (daughter) decides to go back to work. The mother in need of care cannot be left unattended for eight hours. Since there are no other caregivers available and care in kind is not sufficient, there is an entitlement to semi-inpatient care in a day care facility.

The costs for accommodation and meals as well as the investment costs must be borne privately. According to Section 41 of Book XI of the Social Code, the maximum monthly benefits for day-care care are :

689 euros for care level 2
1298 euros for care level 3
1612 euros for care level 4
1995 euros at care level 5

Since January 1, 2015, day-to-day inpatient services are no longer offset against outpatient services. Care allowance, care benefits in kind and day-care care can be used in parallel without restrictions.

Are you aware of the above If additional funds are required for home and / or day-care care and if these funds cannot be raised privately, social assistance ( care assistance ) can be applied for, which must take over the missing benefits as part of the social assistance function, provided that the economic conditions are met to receive social assistance are fulfilled.

Additional ongoing benefits for caregivers

In addition to all of the above-mentioned home care services, social security and reintegration benefits can be provided for caregivers (in the definition of Section 19 SGB XI) ( Section 44 SGB XI). These benefits are not linked to the receipt of care allowance, e.g. B. If the current payments for the services of professional care services have been exhausted, but private home care services are also provided (see the example above in "Partial inpatient care"). The only decisive factor is whether and to what extent home care help is required and is actually provided by the carer (s). The MDK has to comment on this as part of the assessment.

Accident insurance

Nursing staff are included in the statutory accident insurance during the care work ( Section 44 of Book XI of the Social Code). The insurance covers all activities in the area of personal hygiene and, insofar as these primarily benefit the person in need of care, also all activities in the area of nutrition, mobility and housekeeping. The routes to and from the foster home are also insured (source: joint circular). Accident insurance cover also applies to caregivers who are employed for more than 30 hours a week. No accident insurance cover applies to persons who have taken on occasional auxiliary work for the caregiver as part of the delegation because they are not considered caregivers within the meaning of § 19 SGB XI.

Contributions to the statutory pension insurance

Caregivers who care for a person in need of care with at least care level 2, who is entitled to long-term care insurance benefits, for at least 10 hours a week, spread over at least two days, are compulsorily insured in the statutory pension insurance ( Section 3 Sentence 1 No. 1a SGB VI). This does not apply if the carer is already insured with another pension, e.g. B. because they

draws an old-age pension or a pension
in addition to caring for more than 30 hours a week, is otherwise employed or self-employed, subject to compulsory insurance

In the opinion of the central social insurance associations, there is no pension insurance obligation even if the care is not permanent. In this sense, permanent care is exercised if it is designed for more than two months or 60 days a year (not a calendar year).

The insurance relationship is established by law, an application is not required. The decision on whether the requirements for compulsory insurance are met is made by the statutory pension insurance provider. If insurance is compulsory, the long-term care insurance fund pays the mandatory contributions directly to the pension insurance, which is recorded there as mandatory contribution periods.

The amount of the pension insurance contributions is based on Section 166 (2) SGB VI . Fictitious contributory income is used as a basis, which depends on the degree of care and the reference value according to Section 18 SGB IV, as well as on whether the person in need of care claims care allowance, care benefits in kind or the combined benefit.

Monthly pension contributions (in euros):

	Contribution rates west			Contribution rates east
Care level	Care allowance	Combined performance	Care in kind	Care allowance	Combined performance	Care in kind
2	€ 150.21	€ 127.68	€ 105.15	€ 134.30	€ 114.16	0€ 94.01
3	€ 239.22	€ 203.34	€ 167.45	€ 213.89	€ 181.81	€ 149.72
4th	€ 389.43	€ 331.01	€ 272.60	€ 348.19	€ 295.96	€ 243.74
5	€ 556.33	€ 472.88	€ 389.43	€ 497.42	€ 422.81	€ 348.19

When calculating the pension, the periods of care reported to the pension insurance institution, such as periods of insured employment, are offset against the pension. The top social security organizations have explained the pension insurance for inactive carers.

Tax allowance

For the care of family members (in exceptional cases also for the care of other people) who are classified either in care level 4 or 5 or for whom the characteristic "H" (helpless) is entered in the severely disabled person's card , the carer can claim a care lump sum if she has not received any income for care. If higher expenses arise, these can be claimed instead of the lump sum as an extraordinary charge , taking into account the reasonable charge.

Additional services if required

Preventive care ("substitute care")

If the private carer is temporarily prevented from caring for at home, the long-term care insurance covers the proven costs of replacement care (also known as preventive care) for a maximum of six weeks per calendar year and at the maximum amount of 1612 euros that has been in effect since 2015.

Since January 1, 2015, up to 50% (up to 806 euros) of the annual amount earmarked for short-term care may be spent on preventive care at home instead of short-term inpatient care.

The prerequisite is that the caregiver has cared for the person in need of care for at least six months in their home environment before they are prevented from doing so for the first time. ( Section 39 SGB XI).

The substitute worker can be a professional nursing service or a legally placed carer from a service company that is based in the European Union .

If the substitute is related or related by marriage to the person in need of care up to the second degree, or lives in the same household, the benefit is limited to the amount of the care allowance for the respective care level. However, this does not apply if the substitute care is exercised on a professional basis.

Nursing is paid for if

the carer has already cared for another person in need of care for at least 8 days within the last 12 months or
the caregiver takes care of the person in need of care for longer than 4 weeks (28 days) as part of substitute care.

In this case, the maximum amount of 1612 euros is also available to relatives and by-laws.

Actual higher expenses must be proven, for example for cleaning the care clothing, for travel costs, costs for the other accommodation of a child during the care activity, loss of earnings. These additional expenses are paid regardless of the applicable maximum amount. Costs that the caregiver incurs as a result of the absence from work in their own household are not reimbursable.

Care allowance withdrawal while receiving substitute care:

If the funds are used for preventive and short-term care at home, 100% of the granted care allowance is paid for the first and last day of the respective period for the duration of the withdrawal, but only 50% for the days in between. Entitlement to care allowance can also be revived before the 42 days have passed, as soon as the maximum amount of 1612 euros has been exceeded.

If an hourly application for the preventive care allowance or the pro-rata short-term care allowance is made, 100% of the approved monthly care allowance is paid out, i. H. not reduced, provided the time of absence of the registered carer does not exceed 6 hours. The period does not count towards the maximum of 42 days. If the replacement care time exceeds 6 hours, the care allowance is not paid for the day in question. It is advisable to agree an hourly wage with the replacement person.

If the substitute belongs to the immediate family, expenses such as B. unpaid vacation, net loss of earnings, travel expenses, etc. on presentation of a certificate from z. B. reimbursed by the employer.

Short-term care (inpatient)

In the case of short-term care, the costs for inpatient accommodation in a nursing home for up to eight weeks per calendar year are covered up to an amount of 1612 euros (from January 1, 2015, previously 1550 euros). The care-related costs are eligible. The costs for accommodation, meals and investment costs are to be paid by yourself. Reasons for benefits can be discharge from the hospital or a short-term increased need for care (this short-term care is therefore not an independent benefit from long-term care insurance, but an additional benefit in the case of existing home care). Short-term care is subordinate to day-care inpatient care ( Section 42 (1) SGB XI), i.e. the long-term care insurance can have the MDK or Medicproof checked in individual cases whether day-care care is sufficient to cover the need for care.

Care aids

Nursing aids and technical aids are made available regardless of the level of care in question, and regularly on loan ( Section 40 SGB XI). There is an additional payment obligation of 10% for technical aids, but no more than 25 euros per aid. The nursing aids are listed under numbers 50 to 54 in the list of medical aids provided by the statutory health insurance . The need for nursing aids must be confirmed by a nursing service. In inpatient care, care aids are to be provided by the care facility (see below). For “care aids intended for consumption” such as disposable gloves and disposable bed protection inserts, expenses of up to 40 euros per month are covered (application made when purchasing).

Measures to improve the living environment

For the improvement of the living environment (for example attaching handrails and grab handles, removing thresholds and steps by installing ramps, installing wheelchair-accessible kitchen cabinets, installing a bathroom suitable for the disabled, stair lift), the long-term care insurance according to § 40 Abs. 4 SGB XI costs up to A maximum of 4,000 euros per measure can be approved. Since the introduction of the Care Reorientation Act on October 30, 2012, people in need of care are no longer required to pay their own contribution.

The measures must be proposed by the medical service of the health insurance company or a specialist nurse, for example the outpatient nursing service.

If various conversions or installations are required at the same time (for example door extensions and wheelchair ramps and stair lifts), these are all considered to be one conversion measure. A new grant for measures to improve the living environment is only possible if a change in the care situation that has occurred in the meantime requires this. As an alternative to the necessary renovation work, a move to an apartment that meets the needs of the person in need of care can be subsidized. If further expenses to improve the living environment are necessary here, these can also be subsidized. Overall, however, the maximum grant of 4000 euros must not be exceeded in this combination either.

Relief amount

People in need of care (including those with care level 1) are entitled to a so-called relief amount of 125 euros per month according to Section 45b SGB XI . This amount is earmarked for day or night care services, for short-term care, for care services of an approved care service or for so-called low - threshold care offers, in which helpers take care of groups or in the domestic area under care-specific guidance and relieve family carers and provide advice support. These services were introduced with the Care Services Supplementary Act with effect from January 1, 2002.

However, the relief amount cannot yet be claimed in all federal states, because some state governments have not yet issued a statutory ordinance to allow providers for the relief amount.

Full inpatient care benefits

Full inpatient care is subordinate to home and partial inpatient care ( Section 43 (1) SGB XI). Long-term care insurance can have the need for full inpatient care checked by the MDK or Medicproof. The nursing care insurance pays the nursing home a monthly flat rate (in euros):

125 euros for care level 1
770 euros for care level 2
1262 euros for care level 3
1775 euros for care level 4
2005 euros at care level 5

The person being cared for must pay the costs for accommodation and meals, investment costs and any special comfort benefits (see home fee ) themselves, unless the care costs are lower than the flat rates paid by the care insurance; then these also cover the costs of accommodation and meals. Any costs that exceed these lump sums must be borne by the person in need of care.

If the income is insufficient to cover the remaining costs of the inpatient care, also taking into account the dependents who are responsible for maintenance , “ Help for care ” can be requested from the responsible social welfare agency . The responsibility can be requested from the local social welfare office. Applications must also be received and forwarded there ( Section 18 (2) SGB XII).

The delimitation of responsibility - care facility or health insurance - for the provision of the necessary aids can be problematic with full inpatient care. The long-term care insurances are not responsible for the provision of aids in the inpatient area due to the allocation of § 40 SGB XI to the services of home care. The central associations of the health and long-term care funds have adopted guidelines based on the previous case law of the Federal Social Court, which determine the responsibility for the various groups of aids.

Care in fully inpatient facilities for the disabled

Section 43a SGB XI wasinsertedin the first SGB XI amendment law under pressure from the interest groups representing the disabled, the disabled and the federal states (for the justification of the provision, see also Bt-Drs. 13/4521). The facilities of fully inpatient handicapped assistance such as dormitories for mentally ill or mentally handicapped people were originally excluded from the group of service providers of long-term care insurance, although care services are also provided in these facilities or their residents may have a care level. To (weakly) compensate for this exclusion, the long-term care insurance pays 10% of the home remuneration , in individual cases a maximum of 266 euros per month. The benefit normally only relieves the social welfareinstitution, which bears the costs of the stay in the facilityas part of the integration assistance for the disabled according to SGB XII. The Evaluation Guidelines define in Section D 5.2.4 Special features of the assessment in institutions for the disabled.

Services in residential facilities with outpatient care ("Pflege-WG")

With the Care Reorientation Act , § 38a SGB XI was introduced: Here, the coexistence of several people in need of care in an assisted living community is to be promoted and mutual help is thereby supported. This model has proven itself in dementia residential communities , for example . Under certain circumstances, residents of a care flat share are subsidized by care insurance with an additional amount of 214 euros per month:

The flat share must consist of at least three people and a maximum of twelve people. Not all, but at least three people must be in need of care.
The person in need of care must receive benefits for home care from long-term care insurance.
There must be a supervisor who takes on the organizational tasks of the flat share; the requirement that the caregiver actually has to look after the residents himself has now been removed.
It must not be a facility for day-care or in-patient care.

As a rule, living in a care shared apartment excludes the parallel use of day-care services. Partly inpatient services can only be approved in exceptional cases if care in the care shared apartment is not guaranteed due to the special circumstances.

Nursing courses

The long-term care insurances should cover the costs of long-term care courses ( § 45 SGB XI) for relatives and other people interested in voluntary care work. It is not necessary to have a degree of care. The offer is therefore aimed at all citizens. The care courses serve to ensure the quality of care for the people cared for at home and to facilitate care activities (Third Report on the Development of Care Insurance, p. 21). With an amendment to the law on January 1, 2002, the regulation was changed from a “ can ” to a “should” provision in order to make long-term care insurances more obliged to conduct care courses.

Treatment care according to § 37 SGB V in addition to long-term care insurance

The nursing home care after § 37 SGB V as the performance of the public health insurance may be granted in home care in addition to the care insurance benefits, in the majority of cases as a treatment care to ensure the goal of medical treatment. Performance of basic care can not be settled with the insurance company. Treatment care can in principle be granted indefinitely on a medical prescription, for example if injections have to be administered regularly and neither the patient himself nor anyone else living in the household is able to do so.

Nursing at home can also be provided as so-called hospital substitute care in accordance with Section 37 (1) SGB V. In these cases, which are rare for people in need of care, the health insurance benefits also include basic care. Long-term care insurance benefits are suspended during hospital replacement care - only the care allowance is paid for a maximum of four weeks ( Section 34 (2) SGB XI).

In inpatient care, treatment care is part of the long-term care insurance benefits to the care facility; there is no separate entitlement to the health insurance company ( Section 41 (2), Section 42 (2) and Section 43 (2) SGB XI). As a result of the changes that came into force on April 1, 2007 through the GKV Competition Strengthening Act - GKV-WSG of March 26, 2007, there is an innovation that insured persons in fully inpatient care facilities who have a "particularly high need for medical treatment care" ( § 37 para. 2 sentence 3 SGB V) there is still a claim to benefits. The Federal Joint Committee has amended accordingly by order of 10 April 2008, the guidelines for the regulation of domestic nursing. The new regulation relieves the burden on the providers of the care facilities, nothing changes for the residents.

Critical comments on the services

With the introduction of long-term care insurance, the “long-term care risk” has found recognition as a general life risk . Long-term care insurance does not, however, cover all care costs; Firstly, it is only designed as a subsidy for care costs; secondly, certain care expenses are not taken into account.

Long-term care insurance is not a “needs coverage system” but a “budgeting system”. The benefits of long-term care insurance are often not sufficient to cover all the costs, as long-term care insurance only provides grants up to a maximum amount, regardless of how high the time or financial expenditure actually is in the individual case. Therefore, additional services from relatives in the form of personal work or financial expenses are often required. Since the legislature does not adjust the amounts to be paid by long-term care insurance, or not completely, to the rising costs caused by inflation, the proportion of funds to be raised increases over the years.

In the case of outpatient care, additional costs arise when the person in need of care has many of the necessary care services carried out by a care service. In addition, it has an effect here - especially for people in need of care living alone - that only around one hour per day is assessed for housekeeping. In the case of outpatient care by caregivers, the cash benefits paid by long-term care insurance require a private increase as soon as non-family members start working as caregivers, because there is hardly anyone outside the family who does voluntary care.

Long-term care incidents of less than six months do not result in benefits from long-term care insurance (e.g. a 4-month need for care after a serious accident); the nursing home care as a treatment care after § 37 SGB V in this case does not meet the need for help with activities of daily living from also, unless as a hospital replacement care for more than four weeks or if the statutes of the health insurance includes basic care.

Persons who were not insured as a member or family insured for at least two years in the ten years prior to application are not entitled to receive benefits from long-term care insurance until this previous insurance period has been reached. For children, this time is considered fulfilled when one of the parents fulfills it.

Long-term care insurance contributions

Statutory insurance

The funds of the social long-term care insurance are covered by contributions which are to be borne by the insured themselves and - in the case of employees - also by the employer. The contribution rate has been 2.35 percent since January 1, 2015, 2.55 percent since January 1, 2017 and 3.05 percent since January 1, 2019. In addition, there may be a contribution surcharge of 0.25 percentage points for childless people.

Contribution rates

The contributions are calculated for each member from their contribution income, but only up to the contribution assessment limit ( Section 55, Paragraph 1, Clause 1 SGB XI). In 2019, the income threshold is EUR 4,537.50 per month ( Section 55 (2) SGB XI, Section 6 (7) SGB V in conjunction with the respective social security calculation regulations). Members of the agricultural social security system with compulsory insurance pay a percentage surcharge on their health insurance contributions.

The following table lists the various contribution rates and, if necessary, divides them among those who are obliged to pay.

Group of people	Contribution rates since January 1, 2019
Group of people	Insured	Employer*)
Employee u. Ä. (Federal territory except Saxony)	1.525%	1.525%
Employee u. in the Free State of Saxony	2.025%	1.025%
Family insured	0.00%	0.00%
Beneficiaries (including pensioners ); see. Section 55 (1) i. V. m. Section 28 (2) SGB XI	1.525%	0.00% **)
pensioner	3.05%	0.00%
Voluntarily insured persons (e.g. self-employed)	3.05%	0.00%
Surcharge for childless (23 years of age and born after December 31, 1939)	0.25%	0.00%

*) For details on the employer contribution, see employer contribution .

**) The employer pays the share of the long-term care insurance contributions through a later allowance in the case of long-term care according to the allowance assessment rate.

The receipt of benefits from long-term care insurance does not release you from paying contributions if and insofar as B. as an employee or pensioner there is compulsory insurance.

Students can, under certain conditions, be insured with their parents, their spouses or partners without paying any contributions until they reach the age of 25 (plus their time as military or community service or a federal voluntary service according to the BFG for up to 12 months) . They then become a contributory member of the statutory long-term care insurance. The compulsory insurance as a student exists until the end of the fourteenth semester of the course, but no longer than the age of 30. The stated limits for compulsory insurance can be exceeded in certain cases (e.g. extension of the duration of study for family reasons or because of a disability).

In the case of students, income that is subject to contributions is considered to be the monthly requirement that is set according to the Federal Training Assistance Act for students who do not live with their parents.

For compulsorily insured beneficiaries (e.g. civil servants, soldiers , judges), half the contribution rate applies and, accordingly, a benefit claim of half the amount; the employer takes on the other half of the benefits through the allowance .

Development of the contribution rate:

After the introduction of long-term care insurance on January 1, 1995, the contribution rate was initially 1.0%. It increased on July 1, 1996 - with the start of inpatient care benefits - to 1.7% and on July 1, 2008 to 1.95%. On January 1, 2013, the contribution rate was increased to 2.05%. The aim was to refinance the higher service costs that were introduced by the Care Reorientation Act . To finance the expansion of benefits through the Care Strengthening Act I , the contribution rate was increased by 0.3 percentage points to 2.35 percent on January 1, 2015. With the Care Strengthening Act II , a further increase of 0.2 percentage points to 2.55 percent was made on January 1, 2017. As of January 1, 2019, the rate rose by 0.5 percentage points to 3.05 percent.
Up to December 31, 2004, the same contribution rate was valid for childless persons as for insured persons with children, since January 1, 2005 the contribution rate for childless persons was increased by a surcharge starting with the end of the month in which they turned 23 years old increased by 0.25 contribution rate points.
Until March 31, 2004, pensioners received a 50% contribution subsidy from the pension insurance provider, since then they have to bear the full contribution alone; Exception: recipients of a pension from the old-age insurance of farmers : only half the contribution rate is due there, since the other half is financed by the federal government anyway, which would amount to an unnecessary transfer in the federal budget, cf. § 59 SGB XI.
Since July 1, 1996, a higher contribution has to be paid in Saxony : Saxony is the only federal state that has not abolished the day of penance and prayer as a public holiday. The employees therefore bear the contribution of 1% alone; see. § 58 SGB XI.

Contribution surcharge for childless

Members of long-term care insurances who have or had no children of their own, stepchildren or foster children, must pay a contribution surcharge of 0.25 contribution rate points to be borne by themselves at the end of the month in which they turned 23 ( § 55 para. 3 SGB XI). This does not apply to members born in 1939 or earlier and to recipients of unemployment benefit II . The reasons why someone has no children are irrelevant for the supplement obligation. This means that the contribution rate is 1.525% and 2.025% instead of 1.275% or 1.775% (Saxony) of income subject to contributions. The contribution rate to be borne by the employer or the social service provider remains unchanged at 1.175% or 0.675%. Childless members who receive benefits in accordance with SGB III, for example unemployment benefits , do not need to pay the premium themselves. According to Section 60 (7) SGB XI, the Federal Employment Agency transfers a flat rate of 20 million euros per year to the compensation fund of the long-term care insurance for all benefit recipients. Parental status must be proven to the employer or the social security agency, otherwise they must withhold and pay the additional contribution.

The contribution surcharge was introduced with effect from January 1, 2005 by the child allowance law and thus implemented a requirement of the Federal Constitutional Court , which had demanded the contribution-based better treatment of members with children compared to childless contributors. According to the legislator's justification, the contribution surcharge for childless persons should take into account the child-rearing benefits of the parents. In addition to the monetary contribution, parents make the generative contribution that is important to maintaining the system, i.e. they take care of the next generation, on whom the pay-as-you-go social long-term care insurance is dependent for its future financing.

Privately insured

According to SGB XI, the 42 member companies of the Association of Private Health Insurance for 9.41 million people with private long-term care insurance (2016) are responsible for the private long-term care insurance. V. These companies must offer those subject to compulsory long-term care insurance coverage with benefits equivalent to those in Chapter Four of SGB XI (statutory social insurance). Age-related contributions apply to members of the “private long-term care insurance”. The private long-term care insurances work on the basis of the entitlement cover procedure , which means that aging reserves have to be formed. The "benefits" are at least equivalent to those of the social long-term care insurance. However, as in private health insurance, the so-called benefits in kind are replaced by reimbursement of costs .

For the duration of private health insurance in the basic tariff at half the contribution rate according to Section 152 (4) VAG also reduces the contribution to long-term care insurance by half ( Section 110 (2) sentence 3 SGB XI).

Children with private long-term care insurance are also insured free of charge; The same conditions apply as for family insurance under statutory long-term care insurance ( Section 110, Paragraph 1, No. 2 f) in conjunction with Section 25 SGB XI).

Private supplementary long-term care insurance

Many insurance companies offer private supplementary long-term care insurance. The following applies to those with statutory and private insurance: compulsory long-term care insurance only covers part of the costs. Supplementary long-term care insurance can close the financing gap.

The following supplementary insurances are common:

Nursing pension insurance : It is offered as life insurance in which a nursing pension is paid depending on the payments made by the policyholder, which is graded according to the level of need for care. If the insured event - i.e. the need for care - does not occur or does not occur up to a certain age, benefits will be provided as a pension from an agreed age.

Care cost insurance: The costs remaining after advance payment of statutory or private compulsory insurance will be reimbursed. There are tariffs which take over the (proven) remaining costs in whole or in part.

Daily care allowance insurance : Upon proof of the need for care, a fixed amount of money is paid for each care day, regardless of the actual cost of care. The daily allowance is paid regardless of whether care services are used by third parties.

This group also includes the "state-sponsored private supplementary insurance" (also known as "Pflege-Bahr", named after the former Federal Minister of Health Daniel Bahr ): Anyone who pays at least 10 euros a month in favor of a private supplementary long-term care insurance in their name that is eligible for funding, is entitled to an allowance of 5 euros per month. A maximum of twice the social long-term care insurance can be insured. Insurance companies that offer this private supplementary long-term care insurance may neither reject applicants on the basis of previous health conditions nor charge exclusions or risk surcharges. The main criticism was that people with a high risk would therefore conclude contracts, while people who are hardly affected use other offers.

Appeal

Anyone who believes that their rights have been violated by a decision of the long-term care insurance can appeal against the decisions ( administrative act ) of the long-term care insurance ( §§ 77 ff. SGG ). The objection must be submitted in writing or for recording within one month of receipt of the notification. Action can only be brought after the notice of objection has been issued. The courts of social jurisdiction are responsible for disputes in matters of long-term care insurance - including private long-term care insurance ( Section 51, Paragraph 1, No. 2, Paragraph 2 SGG). The social courts are also responsible for disputes between the so-called service providers of benefits in kind and the long-term care insurances. In the case of private law disputes in matters of private compulsory long-term care insurance, there is no objection procedure, so that legal action is open directly.

An objection or a lawsuit can be justified, for example, if

the approved degree of care does not correspond to the actual restrictions;
a requested service has been wrongly refused with regard to the scope or type of service;
an insured person's rights with regard to procedural, membership, contribution or jurisdiction decisions of the long-term care insurance have been violated.

Those involved have the right to inspect files ( Section 25 SGB X), including the respective MDK or SMD reports. Section C 2.8.3 of the assessment guidelines contain special statements on assessment in the objection procedure. A deterioration is also possible. The long-term care insurance is also obliged to provide advice in objection and legal proceedings according to Section 7 of Book XI and in general according to Section 14 of Book I of the Social Code . Objections and lawsuits generally have suspensive effect ( Section 86a SGG), which means that e.g. B. in the event of an objection to the cessation of a service, this will initially continue to be granted for the duration of the procedure subject to a refund.

Long-term care insurance and income tax

For people who are severely in need of long-term care within the meaning of Section 14 of Book XI of the Social Code or who receive long-term care insurance benefits, the income tax is reduced by 20% upon request, but no more than 1200 euros per year. However, long-term care insurance benefits are to be taken into account, with the result that only those expenses lead to a tax reduction that are not financed by long-term care insurance benefits.

Contributions to the PV among the special expenses and are tax-reducing effect as a special edition. Care allowance received is not part of income for tax purposes. For people in need of care, a flat-rate allowance for the disabled comes into consideration, which is granted independently of long-term care insurance benefits and which reduces taxable income. The amount of the lump sum depends on the degree of disability. Applications for a corresponding classification must be submitted to the responsible pension office .

literature

Ronald Richter: The new social long-term care insurance - PSG I, II and III: Concept of care - remuneration - potential. Nomos, Baden-Baden 2017. ISBN 978-3-8487-3719-2
Schmidt, Merkel: Long-term care insurance in questions and answers. 5th edition. dtv, 2013, ISBN 978-3-423-50738-7 .
Thomas Klie: Long-term care insurance. 7th edition. Vincentz, Hannover 2005, ISBN 3-87870-125-X .
Jutta König: 100 errors in the MDK exam and what you can do about it. Schlütersche VB, 2005, ISBN 3-89993-427-X .
Peter Udsching : Social Code (SGB XI), social long-term care insurance. Comment. Beck Juristischer Verlag, 2000, ISBN 3-406-46432-7 .

Web links

Text of SGB XI (§§ to click)

all versions of SGB XI since 2006

Care statistics 2011 (PDF) Federal Statistical Office

Documents of the medical service of the umbrella organization Bund der Krankenkassen e. V. (MDS) on the subject of care

Karlheinz Bayer: Long-term care insurance: Recipes for recovery . In: Deutsches Ärzteblatt . tape 101 , no. 30 , July 23, 2004, p. A-2094 / B-1751 / C-1683 .

Individual evidence

↑ PKV-Info: The private long-term care insurance. (PDF) Association of Private Health Insurance e. V., March 2, 2015, accessed June 12, 2015 .

↑ ^a ^b 48th Conference of Health Ministers (PDF) In: Deutsches Ärzteblatt Heft 2, from January 15, 1982, Volume 79, Issue A / B, p. 22.

↑ Federal Council: Bill of the State of Baden_Württemberg: Draft of a law on precaution against the financial care risk ( PflegeVG) (PDF) of May 28, 1990, printed matter 367/90

↑ In 1991, 543,000 people in need of care received assistance totaling around DM 12.7 billion; that was more than a third of the total social assistance expenditure, cf. Birk, Ulrich Arthur: Commentary on teaching and practice LPK-BSHG , 4th edition. Nomos 1994

↑ Article 1 of the law on social protection of the risk of long-term care (Care Insurance Act - PflegeVG) of May 26, 1994 ( Federal Law Gazette I p. 1014 )

^ Care Reorientation Act of October 23, 2012 ( Federal Law Gazette I p. 2246, 2247 ) Text and amendments to the Care Reorientation Act

↑ BSG, judgment of November 30, 2017, AZ B 3 P 5/16 R

↑ When switching from private health insurance to statutory family insurance there is a risk of a two-year gap in care. Insurance messenger, June 14, 2018.

↑ https://www.sozialgesetzbuch-sgb.de/sgbxi/anlage-1.html

↑ https://www.sozialgesetzbuch-sgb.de/sgbxi/anlage-2.html

↑ Bundestag printed matter 14/6949 (PDF; 431 kB) p. 13 to amend Section 37 (3) SGB XI (quality assurance visit )

↑ Joint circular on pension insurance for non-gainfully employed caregivers (PDF; 315 kB) of the National Association of Statutory Health Insurance Funds, the German Pension Insurance Association and the Association of Private Health Insurance from December 28, 2009, II, 1.1.4

↑ Compulsory pension insurance for carers according to § 3 S. 1 No. 1a SGB VI

↑ BSG judgment of June 6, 2002, Az. B 3 P 11/01 R.

↑ cf. Joint circular

↑ List of resources of the statutory health insurance

↑ [1]

↑ [2]

↑ maintower from Monday, November 20, 2017

↑ kvberlin.de (PDF)

↑ Bundestag printed matter 13/4521 on the justification for § 43a SGB V. (PDF; 371 kB)

↑ Resolution of the Federal Joint Committee on the amendment of the home nursing guidelines of April 10, 2008. (PDF; 278 kB)

↑ Section 4 (2) SVRechGrV 2017

↑ BGBl. 2018 I p. 2587

^ Synopsis § 55 SGB XI

↑ Amendment of § 55 SGB XI through Article 1 No. 25 Letter a) of the Act on the Realignment of Long-Term Care Insurance of October 23, 2012 ( Federal Law Gazette I p. 2246, 2251 )

↑ buzer.de ( page no longer available , search in web archives ) Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Toter Link / www.buzer.de
↑ Law to take into account child-rearing in the contribution law of social long-term care insurance (Child Consideration Act - KiBG) of December 15, 2004 ( Federal Law Gazette I p. 3448 ).
^ Federal Constitutional Court, judgment of April 3, 2001 , Az. 1 BvR 1629/94, BVerfGE 103, 242
↑ Draft of a law to take into account child-rearing in the contribution law of social long-term care insurance (Child Consideration Act - KiBG), Bundestag printed matter 15/3671, pages 4 and 5
↑ Facts and figures PKV Association of Private Health Insurance, accessed on December 23, 2016.
↑ The private long-term care insurance. (PDF; 0.6 MB) Association of Private Health Insurance V., January 2018, p. 5 , accessed on March 18, 2018 : "The non-contributory co-insurance of the policyholder's children is regulated according to the same conditions as in the social long-term care insurance."

This version was added to the list of articles worth reading on November 5, 2006 .

[1] PKV-Info: The private long-term care insurance. (PDF) Association of Private Health Insurance e. V., March 2, 2015, accessed June 12, 2015 .

[ab1982-2] 48th Conference of Health Ministers (PDF) In: Deutsches Ärzteblatt Heft 2, from January 15, 1982, Volume 79, Issue A / B, p. 22.